Years of Life Lost (YLLs) Due to Suicide and Homicide in Ilam Province: Iran, 2014-2018

Objective: To provide detailed of suicide and homicide mortality and calculate of years of life lost (YLLs) in Ilam province Iran, during 2014-2018. Methods: In this cross-sectional study, all deaths due to suicide and homicide were enrolled to estimate YLLs, in Ilam province between 2014-2018. The source of data was legal medicine organization (LMO). All analysis was performed at 0.05 significant levels using statistical software package STATA for Windows version 11.2 and SPSS 21 software. Results: The total YLLs of suicide and homicide were 15685 and 5317, respectively. 522 per 100,000 populations were suicide and 117 for homicide. The YLL and 95% confidence interval form suicide was 34.4 (32.8-36.1) for both sexes that 33.7 (31.6-35.8) for men, and 35.5 (32.7-38.3) for women. In this study period, YLLs rate began to increase over the years in both injury-related in 2016. Conclusion: Results of this study disclosed the most prominent contribution of men and peoples aged 15-29 to the YLLs. Also our results indicate a recent increase in suicide and homicide YLLs for both genders.


Introduction
S uicide and homicide have been a major causes of premature death worldwide and they cause social and economic burden on society [1]. In 2018, 1.4% of all deaths occurred due to suicide. Suicide is the 2 nd leading cause of death for peoples aged 15-29 and homicide ranked 3 rd for the same age group [2].
Suicide burden is gradually projected to increase from 1.8% in 1998 to 2.4% in 2020 [3]. In addition to suicide, homicide also has alarming statistics, therefore, 470,000 homicides have recorded in the world annually. About half of them occur in the 10-29 years of age group and 84% of homicides occur in men [4].
In Iran, suicide rate was 4.3 per 100,000 populations and 4% of total injuries are suicide. Homicide rate was occurred on 6.5 per 100,000 that 80% of victims were men and the mean age of victims were 32. 4 year [5]. In Ilam, suicide has increased gradually in the last decade [6]. In Ilam province, the suicide rate was 19.5 per 100,000 people in 2014-2018 [7]. The national study showed that Ilam has a leading rank of suicide rate among 31 provinces in Iran, 2010 [8]. Based on recent national data, Ilam rates are higher than the national rates for both homicides and suicides. Ilam's homicide rate is 8.1 per 100,000 while the national rate is 6.1 per 100,000. Ilam's suicide rate is 20.7 per 100,000 while the national suicide rate is 5.1 per 100,000 [9]. The highest suicide attempts were observed in peoples aged 15-24. The overall suicide and homicide rate in aged 15-24 were 33.9, and 9.1 per 100,000, respectively [10]. The years of life lost (YLLs) was a versatile index to estimate the burden of injury-related mortality. YLLs have been widely used to evaluate disease burden in public health [11]. In Iran, YLLs rate due to suicide is similar with European countries, although the suicide mortality is much lower, young people are more likely to commit suicide in Iran [12].
Data collection and analysis is essential to understand the problem and support the government and public health agencies for designing intervention strategies and identify risk and protective factors. Therefore, the purpose of this study is to provide detailed of suicide and homicide mortality and calculate of YLLs in Ilam province Iran, during 2014-2018.

Materials and Methods
The present study is a cross-sectional on population living in Ilam province between 2014-2018. The source of data was legal medicine organization (LMO) in Ilam province and all deaths due to suicide and homicide were enrolled in the study. In line with the national laws in Iran, all violent death should be referred to LMO and death certificate is just issued by LMO.
Data were extracted from medical records and death certificate in LMO. The variables in the study were age, sex, marital status, level of education, place of residence, cause of death, years of life lost due to premature death and life expectancy.

Statistical Analysis
The YLLs rats was calculated by decreasing the age of death according to standard life expectancy at a specific age and sex group, through the formula YLL=N*L which in formula N is the total number of deaths (in a specific age and sex group) and L is the life expectancy in the same age and sex group. A Chi-square test was performed to observe the significant differences between groups. All analysis was performed at 0.05 significant levels using statistical software package STATA for Windows version 11.2, and SPSS 21 software.

Results
We combined data in five years 2014-2018 for YLL estimation in suicide and homicide. The total numbers of suicide in the study period were 445 (75.8  Table 2).
The total YLLs of suicide were 15685 (2614 per 100,000 populations) and 5317 YLLs results in in homicide (886 per 100,000 populations) ( Table 3). The percentage of YLL rates over the years by outcome are shown in Figure 1. The year with the highest YLL rate among study period for both outcomes are final study year 2018.

Discussion
This study has been produced to provide the suicide   113  3822  637  39  1525  254  2015  88  3250  541  20  613  102  2016  76  2502  417  23  830  138  2017  81  2649  441  42  1579  263  2018  97  2013  335  20  769  128  Total  455  15685  2614  144  5316  and homicide mortality and calculate the YLLs in total. By main covariates, YLLs rate showed that the total YLL in suicide was 34.4 years and men had a higher contribution to YLL over the period of the study. Brazinova in own study revealed that the suicide risk is higher in men than in women [13]. Results of this study showed that the largest YLLs burden (45.3%) belonged to people aged 15-29 years in both genders. In other study in Iran, the annual self-harm mortality rate was higher in people aged 15-24 years, as well as in men in over a period of 26 years [14]. Curtin et al., showed that suicide attempts are more common in individuals 15-29 years old [15]. Fond et al., reported higher suicide rates in men and individuals aged 15-29 in 25 European countries and United States of America [16]. Based on result of the Global Burden of Disease (GBD), 1.3% of total DALYs were related to self-harms and suicide rank was 3 during 1990-2016 [17]. The reason for this result is men and people aged 15-29 who are in more stressful situations than other groups. Also, they may have dissimilarities in attitudes toward suicide.
According to the results of this study, homicide was more occurred in men 116 (80%). A study was reported a 10 years' trend of homicide and showed that Ilam province had a higher annually incidence in Iran (4.4 per 100,000 persons) [18]. Other studies that conducted in Europe and Asia countries reported much more prevalence in men [19,20]. The total YLLs due to suicide and homicide were 522 and, 177 YLLs per 100,000 populations, in both genders, annually. A national study in 2020 showed that YLLs due to suicide was 345 per 100,000 populations [12]. We investigated YLLs rate over the years and resulted that suicide and homicide rates began to increase in 2016. The present study indicates that recent increases were for both suicide and homicide. A national study in Iran between 2006-2016 showed a significantly decreasing rate [9] whereas, the fairly constant slop in homicide incidence rate was reported in Russia between 2001-2009 [21]. Therefore, homicide have a different trend changes in different countries.
The results of the present study revealed a higher rate of YLLs in suicide and homicide in Ilam province compared to other region in Iran. Our results disclosed the most prominent contribution of male gender and persons aged 15-29 to the YLLs. Also our results indicate a recent increase in suicide and homicide YLLs for both genders. There is a national need to implement an effective health policy intervention in order to save the burden of suicide in Ilam by considering that most of such deaths are preventable.

Declaration
Ethics approval and consent to participate: This study was undertaken with the approval of the ethical committee of Legal Medicine Organization, Islamic Republic of Iran (IR.LMO.REC.1398.042).

Consent for publication:
The authors express their consent to the publication of the article.

Conflict of interests: Authors have no conflict of interest.
Funding: This study was supported by Legal Medicine Organization, in Ilam province.
Authors' contributions: Yousef Veisani had participated in the study design, literature review, preparation, and editing of the manuscript. Amin Bakhtiyari had participated in the study design, data collection, preparation, and editing the manuscript. Fathola Mohamadian had participated in the study design, data collection, preparation, and editing of the manuscript. All authors reviewed the preliminary and final analyses, and the draft and final manuscripts. All authors read and approved the final manuscript.